A soldier hugs his child during a homecoming ceremony at Fort Bliss, Texas: Because of familial strains or trauma of war, soldiers say it is harder coming home than leave. Zhang Jun/Xinhua Press/Corbis

January 20, 2012

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What challenges do new veterans face?More than 2.3 million soldiers have served in Afghanistan and Iraq over the past decade, and official fatality and casualty numbers — 6,179 dead, 47,000 wounded — fail to capture the extensive physical and psychological injuries many of them have suffered. The Veterans Administration has treated more than 210,000 veterans of those wars for post-traumatic stress disorder, but acknowledges a much larger epidemic, since the stigma of mental-health problems prevents many of them from seeking help. Vets are also returning to marriages and families strained or broken by multiple deployments, few employment opportunities, and a country largely oblivious to the wars in which they served, heightening their feelings of loneliness and alienation. "It's harder coming home than leaving — anyone will tell you that," says Col. Michael Gaal, who served in Iraq.

What kinds of wounds have they suffered?Wounded soldiers are far more likely to come home alive today than in past wars, thanks to advances in combat medicine, faster evacuations, and better body armor. In Vietnam, 2.6 soldiers survived their wounds for every battlefield death; in Iraq and Afghanistan, the ratio is 16 to 1. But that means thousands are returning with catastrophic injuries, such as double and triple amputations and debilitating spinal cord damage, and they need special, long-term care. The use of improvised explosive devices by insurgents has caused a huge increase in traumatic brain injuries, widely considered the "signature injury" of these wars, with at least 218,000 cases diagnosed over the past decade.

What are traumatic brain injuries?They range from penetrating head wounds to concussions sustained through exposure to massive bomb blasts. Diagnosis can be difficult; blast waves can cause micro-concussions that damage brain cells even of soldiers who are not counted among the wounded. "There are combat wounds you can see, and others that are invisible until symptoms develop," says clinical psychologist Barbara Van Dahlen. Even mild brain injuries can lead to a range of cognitive, behavioral, and emotional problems, including difficulty concentrating, memory loss, and depression. Symptoms often overlap with those of PTSD, making it hard to determine whether soldiers are suffering a psychological problem, a brain injury, or both.

Are these problems widespread?Iraq and Afghanistan Veterans of America estimates that nearly one in three recent vets — or more than 700,000 of them — suffers from PTSD, depression, or brain injury. Blackouts, flashbacks, night terrors, and sudden rages are common among veterans; suicide, alcoholism, and drug use have surged. PTSD has been cited as a factor in many acts of vets running amok, such as this month's killing of a Mount Rainier National Park ranger by a 24-year-old Iraq returnee. Since PTSD symptoms can emerge long after service ends, fallout from the disorder is likely to increase. "When you look at the epidemic of PTSD, you see the future," says Harvard professor Linda Bilmes.

Are vets getting the help they need?Many are not. "No one was really prepared for the number of seriously wounded survivors," says Dr. Ronald Glasser, the author of a book on battlefield medicine. Wounded veterans have swamped the VA system, leading to a backlog of almost 900,000 disability claims. Vets complain of a burdensome bureaucracy, lost paperwork, redundant medical exams, and inconsistent diagnoses. "You fight for your country, then come home and have to fight against your own country for the benefits you were promised," said Clay Hunt, a Marine sniper who was shot in the wrist in Iraq, and had to wait 10 months for disability checks. Depressed, divorced, and haunted by the loss of several close friends in battle, Hunt killed himself last March.

What will their long-term care cost?Hundreds of billions of dollars. Studies show that the cost of health-care and disability payments for veterans of past wars did not peak until decades after the last bullet was fired. The peak year for paying out disability claims to World War I veterans was 1969, and care costs for Vietnam vets have not yet crested. Because of the high survival rates and the many cases of PTSD and brain injuries, it's been estimated that the medical and disability costs for Iraq and Afghanistan veterans over the next 40 years could reach $930 billion.

Are returning vets getting jobs?Many find that their old jobs have disappeared, or that potential employers are skeptical about the value of their military service. Unemployment among recent vets is 13.1 percent, compared with the national level of 8.5 percent. One in three vets between the ages of 18 and 24 — many of whom had scant education or work experience when they deployed — is now jobless, twice the rate for non-vets of the same age range. "The spike in new veteran unemployment should be a serious wake-up call for the country," says Paul Rieckhoff, the executive director of Iraq and Afghanistan Veterans of America. "The tide of war might be receding, but the surge home is just really beginning."

A new kind of wound Marine Lt. Col. Mike Zacchea took shrapnel in his shoulder during the battle of Fallujah, but only back home in Long Island, N.Y., did he realize he'd also sustained invisible wounds. "I thought I was just going to pick up my life where I left off," he says. "That was a mistake." He didn't speak to anyone for the first six months at home. One night he set his bathroom door on fire after mistaking his wife, who was locked inside, for an insurgent. Doctors said Zacchea probably suffered from traumatic brain injury, but the plight of vets like him is still poorly understood. Four years ago the military was ordered to test every service member's brain before and after deployment. But the $42 million effort, plagued by faulty tests and poor administration, has yielded little new insight. "We have failed soldiers," says retired Col. Mary Lopez, who once oversaw the program. "I can see firsthand the soldiers that we've missed, the soldiers that have not been treated, not been identified, misdiagnosed. And then they struggle."